Phone *
Email *
Number of Years at Current Address *
If Less Than 3 Years, List Prior Address
Number of Owners * Choice 1 1 2
Gender - Insured Person 1 Choice 1 Male Female
Marital Status - Insured Person 1 * Choice 1 Single Married Domestic Partner Separated Divorced Widowed
Occupation - Insured Person 1
Level of Education - Insured Person 1 Choice 1 Less Than High School High School Some College Community or Junior College Bachelor's Degree Master's Degree PhD Law Degree Medical Degree
Are You a AAA Member? - Insured Person 1 Choice 1 Yes No
Are You an AARP Member? - Insured Person 1 Choice 1 Yes No
Gender - Insured Person 2 Choice 1 Male Female
Marital Status - Insured Person 2 Choice 1 Single Married Domestic Partner Separated Divorced Widowed
Social Security Number - Insured Person 2
Occupation - Insured Person 2
Level of Education - Insured Person 2 Choice 1 Less Than High School High School Some College Community or Junior College Bachelor's Degree Master's Degree PhD Law Degree Medical Degree
Are You a AAA Member? - Insured Person 2 Choice 1 Yes No
Are You an AARP Member? - Insured Person 2 Choice 1 Yes No
Do You Currently Have Insurance? * Choice 1 Yes No
If Yes, Who is the Current Carrier?
How Long Have You Been With This Company? Choice 1 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12+ Years
Prior Coverage Amount On Dwelling? *
Prior Coverage Amount on Other Structures
Prior Coverage Amount On Personal Property?
Prior Coverage Amount On Loss or Use?
Prior Liability Limit Choice 1 $100,000 $200,000 $300,000 $400,000 $500,000
Prior Medical Payment Limit Choice 1 $1,000 $2,000 $5,000
Deductible * Choice 1 $500 $1,000 $1,500 $2,000 $2,500 $5,000
Wind/Hail Deductible * Choice 1 $1,000 $1,500 $2,000 $2,500 $5,000 1% 2%
Do You Have Coverage for Earthquake? Choice 1 Yes No
Year Built *
Total Square Footage *
Type of Home * Choice 1 1 Story 2 Stories 1.5 Stories Bi-Level Tri-Level
Construction Type * Choice 1 Masonry Veneer Frame Vinyl Siding Log Other
How Many Acres?
Any Mortgage? * Choice 1 Yes No
Number of Full Bathrooms and Half Bathrooms *
Basement * Choice 1 Yes No
Sunken or Walkout Basement? Choice 1 Sunken Walkout
Is the Basement Finished? * Choice 1 Yes No
If so, What Percent is Finished? Choice 1 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Heat Type * Choice 1 None Gas Oil Electric Geo Thermal
Wood Burning Stove? * Choice 1 Yes No
Central Air Conditioning? * Choice 1 Yes No
Complete Update to Wiring? * Choice 1 Yes No
If Yes, What Year?
Complete Update to Heating? * Choice 1 Yes No
If Yes, What Year?
Complete Update to Roofing? * Choice 1 Yes No
If Yes, What Year?
Complete Update to Plumbing? * Choice 1 Yes No
If Yes, What Year?
What Type of Roof? * Choice 1 Asphalt/Composition Shingles Metal Other
If Shingles, What is the Warranty? Choice 1 0 - 20 Years 21 - 35 Years 36+ Years Unknown
Garage/Car Port? * Choice 1 None Garage Car Port
Garage/Car Port Size Choice 1 1 Car 2 Car 3 Car
Swimming Pool? * Choice 1 None Above Ground In Ground
If There is a Swimming Pool, is it Enclosed With a Fence and a Locked Gate? Choice 1 Yes No
If There is a Swimming Pool, Does it Have an Elevated Diving Board (More Than 1 Step)? Choice 1 Yes No
Trampoline? * Choice 1 Yes No
If Yes, is the Trampoline Enclosed in a Fence, Locked Gate, and surrounding net? Choice 1 Yes No
Any Other Structures on Property? If so, Describe
Are There Any Pets With Bite History or any Exotic, Undomesticated, or Vicious Animals On The Premises? * Choice 1 Yes No
Any Dogs? * Choice 1 Yes No
If Yes, is the Dog One of the Following Breeds? Choice 1 Rottweiler - Full Breed Rottweiler - Part Breed Doberman - Full Breed Doberman - Part Breed Pit Bull (All Variants) - Full Breed Pit Bull (All Variants) - Part Breed Akita - Full Breed Akita - Part Breed Husky/Malamute - Full Breed Husky/Malamute - Part Breed Chow - Full Breed Chow - Part Breed German Shepherd - Full Breed German Shepherd - Part Breed Presa Canarios - Full Breed Presa Canarios - Part Breed Great Dane - Full Breed Great Dane - Part Breed No
Are There any Business Pursuits Being Conducted on the Premise? * Choice 1 Yes No
Smoke Detectors? * Choice 1 Yes No
What Kind of Alarm Do You Have? * Choice 1 None Local Fire Local Burglary Local Fire and Burglary Central Fire Central Burglary Central Fire and Burglary
Is Your Residence Located 5 Miles or Less From the Primary Responding Fire Department? * Choice 1 Yes No
Is there a fire hydrant within 1000 feet? * Choice 1 Yes No
Who is the Primary Responding Fire Department?
Is the Residence a New Purchase? * Choice 1 Yes No
What's The Purchase Price?
Any Losses or Claims in the Last 5 Years? * Choice 1 Yes No
If Yes, Please List the Dates and a Brief Explanation of Each Claim or Loss
